Texas workers caring for elderly feel “treated like a stepchild” as caseload increases, pay stays the same

Charla Gilliam, an Adult Protective Services specialist in Houston, calls a client as she’s on the way to an in-home checkup in June. Pu Ying Huang for The Texas Tribune

HOUSTON — Charla Gilliam has her morning routine down pat, complete with her gospel music, Joel Osteen sermons and reading case files for vulnerable older adults and disabled people she needs to see.

As an Adult Protective Services caseworker for the state, she has 40 or more cases of peoplewho have been reported to the agency for potential abuse or neglect.

“You’re going to be praying to somebody when you go to these different places,” Gilliam says as she pulls into a driveway on a rainy June morning.

She’s visiting the first home on her list. It’s a physical neglect case she’s preparing to close soon about a man in hospice care at home with his wife. His wife called Adult Protective Services accusing the hospice company of purposely taking away the machine that helps him breathe. The machine was replaced but Gilliam’s following up.

She has other people she’s watching out for. There’s the man whose family padlocked the refrigerator shut. There’s the man who became paralyzed after a suicide attempt. There’s the husband who took his wife with multiple sclerosis off of his health insurance plan after finding out he wasn’t the father of their child.

“A lot of the time you just never know what you’re walking into,” Gilliam said.

The agency — which is part of the Texas Department of Family and Protective Services — is experiencing high caseworker turnover and caseloads as these staffers work through the emotional toll of supporting and providing services for older and disabled Texans. Caseworkers are also unhappy about workers at Child Protective Services — which is also part of the department — getting significant raises after high-profile scrutiny from media and state leaders. As legislators head back to Austin for the 2019 legislative session in January, it’s unclear how much attention the agency focused on protecting vulnerable adults will receive.

“I do not want a client to die because we didn’t do our job and do it to the best of our ability,” said Kezeli Wold, associate commissioner for Adult Protective Services.

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Caseworkers like Gilliam watch heartbreaking situations of older and disabled Texans not taking care of themselves, being hit, forgotten, or financially exploited. That’s on top of job hazards like foul stenches, roaches, rats and bed bugs. In fiscal year 2017, Adult Protective Services confirmed 51,314 cases of abuse, neglect, or exploitation.

Anyone can confidentially report to the agency online or by phone if they suspect a person 65 years or older or an adult with disabilities is being abused, neglected, or exploited. While Adult Protective Services is often looked at as the Child Protective Services for adults, the two agencies differ. Both conduct investigations and provide services, but the adult agency doesn’t remove people from their homes like Child Protective Services does. Workers may connect clients to services like shelter, food, medication, transportation and assistance paying rent and utilities. But there’s nothing they can do when clients who are dealing with memory or comprehension issues decline help. In addition, the agency doesn’t keep track of deaths like the child welfare agency does.

Wold said he loses sleep thinking about what could happen to clients as turnover in his agency continues. In the first three quarters of the 2018 budget year, 17.4 percent of its workforce left the agency, according to a Texas Department of Family and Protective Services report released in August. The agency, which has 524 caseworkers statewide, projected it would lose 78 first-year workers before the end of the budget year. The fiscal year has ended, but the department doesn’t have new turnover numbers available.

“We’re relatively unstable,” Wold said. “When you have turnover in a complex job like APS best case scenario you become inefficient, worse case scenario somebody makes a poor decision or somebody fails to identify a root cause or fails to identify a safety issue.”

Lots of turnover means caseworkers need to visit more people. There is no national standard for how many clients a caseworker should have. In fiscal year 2017, the average daily caseload for Texas caseworkers was 33.8, but went down to 30.9 the following year. Theagency said in its most recent quarterly report that the workloads “remain higher than ideal” despite the numbers going down slightly.

The problems with high turnover and increased workloads is similar to what Child Protective Services was experiencing two years ago. At the time, the child welfare agency was making headlines over children sleeping in state offices, overworked caseworkers and some endangered children going unseen by workers. During the 2017 session, legislators made a sweeping overhaul of the program and right before that increased worker salaries by $12,000. Agency officials and child welfare advocates credit the raises for the decreased staff turnover and caseloads. In fiscal year 2016, Child Protective Services caseworker turnover was 25.3 percent. It dropped to 18.4 percent the following year.

But after the child welfare agency’s salary increases, Adult Protective Services saw a 24-percent uptick in turnover — and that number doesn’t include at least 27 workers who switched to Child Protective Services after the raises went into effect.

“Staff leaving APS places additional stress on the staff who remain at APS, as remaining staff work abandoned caseloads from peers who leave,” agency officials wrote in their budget request. “New hires are quickly faced with high caseloads due to the constant turnover, soon become stressed, and often quit before they have been with APS for a year.”

“You kind of get treated like a stepchild,” she said. “You got to care about people to do this job.”

Wold and other agency officials are hoping legislators will approve their $17.8 million request for worker raises. If approved, 517 staffers would receive a $12,000 annual salary increase.

“Sometimes we do feel like we don’t get enough attention,” Wold said. “Not just from the Legislature, but from the media and from the community and so we do feel like we have to continually try to get our message out, make sure people are aware of who we are and what we do.”

“This has been an identified issue for a while and they need additional funding to keep up with Texas’ aging population and the fact that more Texans are experiencing abuse and exploitation,” Morstad said.

In a strategic plan published in March, Adult Protective Services raised the alarm about high turnover, and indicated that the program is “too small to adequately address the needs” of the growing older adult population. Agency leaders also cited a lack of adequate funding and a lack of legislative awareness as problems.

Anne Heiligenstein, the Texas Department of Family and Protective Services commissioner from 2008 to 2011, said it was tough balancing attention between the adult and child welfare agencies. Child Protective Services is a larger program than Adult Protective Services and when attention is on child abuse or deaths, “that does absorb much of your time as commissioner.”

“He was the one that could go to the Legislature and say ‘I send 23- and 24-year-olds into homes I wouldn’t send officers into without backup,’” Heiligenstein said. “The danger factor may not be as high in APS cases but the homes that you’re going into, certainly the upsetting things that you have to see and do … the emotional toll that has to take on the caseworker in order to be able to do that.”

Wold said it’s hard to explain to people why adult clients stop bathing, eating, taking their medications or refuse help with their plumbing or housekeeping. Explaining child welfare is simpler.

“To be blunt, children are cute,” Wold said. “Everyone loves kids and everyone knows that children shouldn’t be abused. I think that’s a very easy thing to agree on.”

The last time the adult welfare agency received legislators’ full attention — and ire — was during the 2005 legislative session. News out of El Paso and Tarrant counties found caseworkers botched cases where older clients were living in homes without water, electricity or gas, or among garbage and fecal matter. Some clients were living in their cars to escape their conditions. Others were dealing with mental health issues that caseworkers weren’t helping them to address. Gov. Rick Perry issued an executive order in April 2004 directing the Texas Health and Human Services Commission to investigate and overhaul the agency. Officials reviewed cases involving 200 clients who had three or more referrals to Adult Protective Services and found caseworkers often poorly coordinated services for clients and didn’t always take a client’s mental health into consideration.

Changes included having a caseworker fill out a survey noting the client’s living conditions, financial status, physical/medical status, mental health and social support. The goal of the survey was to provide a fuller assessment of client needs. The agency also streamlined guidelines for referring clients for services; increased access to worker training; updated the guardianship program and hired more caseworkers.

The agency was shellshocked with all of the changes, said Karl Urban, assistant commissioner for Adult Protective Services, from 2005 to 2008. He said it took time for the agency to feel stable again after getting intense Legislative scrutiny. APS workers are often “the most wonderful, life-affirming people” but the challenge remains over how to motivate and retain them.

“You’re dealing with individuals who have the right of self determination, they have the right to make their own decision,” Urban said. “You have to have the right process and protocol in place when they’re capable to make those decisions when it’s appropriate and when it’s not and that’s just inherently difficult.”

Back in Houston, Gilliam had forgotten to use bed bug spray before going inside her second client’s home. The agency doesn’t help caseworkers pay for exterminators if they get bed bugs or ticks from the homes they visit.

Her second client was what is known as a self-neglect case. Someone had reported the woman over the condition of her home. When Gilliam first went in March, she found the woman lying in bed with a dog bleeding beside her.

Charla Gilliam, a specialist at Adult Protective Services, peers through a doorway at an elderly woman she’s visiting in June as the woman’s son listens to their conversation. Gilliam was assigned to the case because the woman was neglecting herself. Pu Ying Huang for The Texas Tribune

Gilliam now stood at the bedroom door as the smell of urine burned the air. The client’s son had pulled up the house’s carpeting to reduce the odor but to no avail. An older woman sat on a mattress on the floor, as she told Gilliam about her foot pain and said she was unable to deal with visitors that day. Gilliam left an application for the Rebuilding Together Houston program, which repairs homes of older adults, people with disabilities and veterans; she told her to call if she needed help with it. She said she would note in her report what resources she gave and what the home was like.

“Sometimes I don’t have the word to describe the smell,” Gilliam said. “I guess my vocabulary is not that extensive.”

Gilliam often leaves clients’ homes feeling angry, sad or frustrated that she can’t do more. In the case of her second client that day, there were agencies Gilliam could connect her with to get the home cleaned. But agencies often want clients to show what they would do differently going forward to maintain their home; some won’t help at all without a plan.

Listening to stories like that is why Rep. Armando Walle, D-Houston, says he pays attention to the issue. Walle, a former member of the House Committee on Human Services, filed House Bill 482 during the 2017 session that would have directed the agency to not give caseworkers more than an average of 22 cases. That bill was passed out of the committee but stalled before reaching the House floor.

“I don’t want to be critical of any of our members but it’s not seen as or perceived to be an issue — that’s my gut feeling,” Walle said. “We got a lot of state issues that we have to deal with and this is one that doesn’t get a lot of play and it should.”

At the third house of the day, Gilliam made sure to use bed bug spray, stopping to shimmy the can down from her knees to her shoes. The couple she was checking on cautioned that she should. It was another self-neglect case that had landed on her desk the past week. The wife didn’t have her insulin and the husband needed help with cooking and cleaning. Gilliam had brought insulin and food last week. There was food in the fridge at the time but it looked old.

The wife was sitting outside in her car. She was upset that the couple’s phones were shut off because they hadn’t paid the bills. Gilliam told her the agency could help the couple pay for their home phone but not the cell phones, due to agency policy. The woman said she wanted to be left alone at the moment. Gilliam soon left.

As she drove back to the agency office, she said legislators won’t truly understand what caseworkers go through until they see and smell it themselves.

But despite the pains of the job, Gilliam said her experience has taught her the importance of making a care plan for herself so she won’t have to depend on her family.

“It’s like it’s real because you’re almost there,” Gilliam said. “Life is not promised, you don’t know what’s going to happen.”

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